Wasting and obesity in HIV outpatients

With the advent of highly active antiretroviral therapy (HAART), it might have been hoped that HIV-associated wasting would become very rare. Early reports demonstrated reconstitution of body mass in wasted individuals treated with HAART [1,2]. However, a recent cohort study in a USA inner city population showed an incidence of wasting of approximately 30% (over 30 months of follow-up) and found similar figures in those patients receiving HAART as in those who were untreated [3]. Such an apparent paradox led us to investigate the incidence of wasting and excess weight in our own clinic population. For all consecutive patients attending an HIV clinic in south London in February 2001, body weight and height were recorded, together with age, race, sex and treatment status. Body mass index (BMI) was classified according to World Health Organization (WHO) criteria [4]. Wasting was defined as a BMI less than 18.5 kg/m2, marginally underweight was a BMI of 18.5–20 kg/m2, normal weight was a BMI of 20–25 kg/m2, overweight was a BMI of 25–30 kg/m2, and obesity was a BMI of 30 kg/m2 or over. Of the 162 subjects recruited, 134 (83%) were on HAART at the time of measurement; 95 (59%) were men; approximately half were Caucasian (78, 48%); the remainder were black (83, 51%) with one Asian. The median age was 38.2 years, and the median BMI was 23.7 kg/m2. Nine patients (6%) were wasted, 11 (7%) were marginally underweight. At the other extreme, 55 (34%) were overweight, and 15 (9%) were obese (Fig. 1). Women had a higher BMI (25.7 versus 23.4;P = 0.001) than men. Black Africans had higher BMI values than Caucasians (25.5 versus 23.2;P < 0.001). Twelve out of 15 (80%) obese patients were African women, in contrast to 43 out of 147 (29%) non-obese patients [odds ratio (OR) 9.7, 95% confidence interval (CI) 2.8–32.5]. HAART was not associated with being overweight or obese (OR 1.6, 95% CI 0.7–3.7). Among the patients with wasting, all but one were on HAART at the time of measurement.Fig. 1.: Population distribution of body mass index in a cohort of HIV outpatients (n = 162). BMI, Body mass index.The prevalence of wasting in this outpatient population was 6%. Our data appear to show significantly less wasting than the US cohort incidence study quoted above [3]. Some of this difference can be ascribed to variations in study populations, design and the definition of wasting. Wanke et al.[3] included patients we classified as marginally underweight (BMI 18.5–20 kg/m2); including these patients would yield a prevalence of 12%. This prevalence appears to be far lower than that seen in the pre-HAART era, although we do not have directly comparable historical data. Such a reduction in wasting would be consistent with the UK national experience. The frequency of wasting as an AIDS-defining diagnosis has fallen by 77% since 1992, in parallel with the reduction in total AIDS cases (Fig. 2). In the UK, the proportion of AIDS diagnoses based on wasting has remained stable at approximately 7–10%.Fig. 2.: Total AIDS cases and number with wasting as a first AIDS-defining condition by year at diagnosisa. ––▪–– Number of AIDS diagnoses based on wasting; – –•– – total AIDS cases. aNumber, particularly for recent years, will rise as further reports are received.Despite HAART, wasting continues to be a problem for a subgroup of patients, including those on treatment, but may be difficult to discern from lipoatrophic lipodystrophy. The striking finding of this study is the high prevalence of obesity among HIV patients, especially in black African women, as previously described in the USA [5]. This may reflect current trends in the general UK population, mixed with an increased occurrence of lipodystrophic fat accumulation. Irrespective of the causes and management of the lipodystrophy syndrome, obesity is likely to have similar adverse long-term consequences in HIV-infected patients as in the general population. Dietary and lifestyle advice should be regularly provided in HIV outpatient clinics for this increasing proportion of patients. Lisa M. Hodgsona Hala Ghattasa Helen Pritchitta Achim Schwenka Lara Payneb Derek C. Macallana